Davao Medical School Foundation, Inc.

Medical School Drive, Bajada, Davao City

College Of Nursing

In Partial Fulfillment of the Requirements

In NCM 103 RLE

A Case Study On

GOITER

SUBMITTED TO:

Ma. Elsie S. Callueng RN., MAN

Clinical Instructor

SUBMITTED BY:

Alonday, Christine Joy R. ST.N

Bawa-An, Ephraim Fritz ST.N
Hilario, Anthony Luigi ST.N
Kasuyo, Fardejah ST.N
Melira, Jelanie ST.N
Parajo, Venice Athena ST.N

June 26, 2017

 TABLE OF CONTENTS

I. INTRODUCTION----------------------------------------------------------------------------------------3
A. Background of the study-----------------------------------------------------------------------3
B. Significance of the study-----------------------------------------------------------------------3
C. Relevance of the study-------------------------------------------------------------------------3

II. OBJECTIVES--------------------------------------------------------------------------------------------5
A. General objectives-------------------------------------------------------------------------------5
B. Specific objectives-------------------------------------------------------------------------------5

III. PATIENT PROFILE-----------------------------------------------------------------------------------6

IV. HEALTH HISTORY------------------------------------------------------------------------------------7

V. GENOGRAM--------------------------------------------------------------------------------------------8

VI. GENERAL ASSESSMENT-------------------------------------------------------------------------9

VII. DEVELOPMENTAL THEORIES AND TASKS----------------------------------------------10

VIII. NURSING THEORIES----------------------------------------------------------------------------11

IX. ANATOMY AND PHYSIOLOGY-----------------------------------------------------------------13

X. DEFINITION OF TERMS---------------------------------------------------------------------------16

XI. ETIOLOGY--------------------------------------------------------------------------------------------17

XII. PATHOPHYSIOLOGY-----------------------------------------------------------------------------19

XIII. SYMPTOMATOLOGY----------------------------------------------------------------------------20

XIV. DIAGNOSTIC TESTS-----------------------------------------------------------------------------21

XV. MEDICAL AND SURGICAL MANAGEMENT-----------------------------------------------27

XVI. NURSING CARE PLAN--------------------------------------------------------------------------29

XVII. DISCHARGE PLANNING----------------------------------------------------------------------36

XVIII. PROGNOSIS--------------------------------------------------------------------------------------39

XIX. RECOMMENDATIONS---------------------------------------------------------------------------41

XX. BIBLIOGRAPHY/ REFERENCES-------------------------------------------------------------42

I. INTRODUCTION

A. Background of the study

Goiter is a swelling of the neck or larynx resulting from enlargement of the thyroid
gland (thyromegaly), associated with a thyroid gland that is not functioning properly.
The degree of swelling, and the severity of symptoms produced by the goiter depend
on the individual. Some cases involve a small amount of swelling, and others can
involve considerable swelling that actually constricts the trachea and causes
breathing problems.

Worldwide, the most common cause for goiter is deficiency, The prevalence
of goiter in areas of severe iodine deficiency can be as high as 80%. Populations at
particular risk tend to be remote and live in mountainous areas in South-East Asia,
Latin America and Central Africa. Iodization programs are of proven value in
reducing goiter size and in preventing goiter development and cretinism in children.
Autonomy can develop in nodular goiters leading occasionally to thyrotoxicosis and
iodization programs can also induce thyrotoxicosis, especially in those aged >40
years with nodular goiters

B. Significance of the study

This study will be a significant endeavor in understanding this condition, it will
help the students and clinical instructors in gaining more knowledge that will help
them deal with future similar cases. By being able to encounter this case and study
it, students will become more competent and expectedly will be more confident with
them. Furthermore this research will provide recommendations on how to plan and
proper nursing interventions for the said case.

C. Relevance of the study

We had found this case to be interesting and challenging on our part as student
nurses since it’s our first time to encounter it. And we were able to relate to it since
its one of the most common diseases that affect the thyroid gland In the Philippines,
Based on the studies of urinary iodine levels conducted by the Department of
Health, most goiter cases are found in the mountainous provinces and other remote
areas of the country. The Food and Nutrition Research Institute performed a
nutritional survey in 1998 to assess the extent of iodine deficiency among 10,616
school children aged six to 12 years. It was discovered that the country as a whole
had mild iodine deficiency.
II. OBJECTIVES

A. General objectives
At the end of our two-week exposure in the Davao Medical School
Foundation Hospital, medical- surgical ward, we will be able to acquire knowledge
and reliable information about goiter in order for us students to become
knowledgeable; be able to demonstrate competent nursing care that will address our
patients condition; and to demonstrate right attitude and provide quality nursing care.

D. Specific objectives
This case study is made to achieve the following reasons:
1. Establish rapport with our patient as well as her significant others to gain trust
and cooperation.
2. Collect significant information regarding our patient’s conditions as well as the
family history, past and present health history.
3. Evaluate client’s data according to the nursing and developmental theory
4. Describe the structures and normal function of the body organs involved.
5. Trace the Pathophysiology of the disease process and its enduring
symptomatology.
6. Review and interpret medical order and results of possible laboratory
examination that the client has undergone.
7. Identify the different signs and symptoms, as well as the presentation of its
etiology and contributing factors in the development of this condition.
8. Make effective nursing care plans that address the present and possible
needs.
9. Enumerate client’s medications which include both therapeutic and the
adverse effects.
10. Present discharge plan for client’s condition.
III. PATIENT PROFILE

Name: Pie

Sex: Female

Age: 39

Status: Married

Address: JPMI, Dona Pilar, Sasa, Davao City

Nationality: Filipino

Religion: Pentecostal

Occupation: Cashier

Birthdate: October 10, 1977

Mother: Apple pie

Father: Pineapple pie

Spouse: Pinay pie

Chief complaint: Goiter

IV. HEALTH HISTORY

History of present illness

Patient has a diagnosed case of “goiter” at local hospital, and was advised for further
treatment, patient was given thyrax which patient was taking once a day for 30 days,
also advised to take vitaplus m+3 as supplemental meds.

Persistent symptoms prompted the patient to seek medical assistance and was advised
for ultrasound at January, 2016 which showed 9.6 cm mass at left thyroid.

Last month prior to admission patient has 1 episode of epistaxis and meds was given
(unrecalled name).

Patient was advised by Doc Pen for surgery on 27 October, 2016 and was advised not
to take any supplement meds for 10 days.

Patient had no recent weight loss, (-) hoarseness, decrease in appetite or any other
associated symptoms.

Patient was brought to our institute for scheduling the surgery and for further evaluation
and management.
 V. GENOGRAM

Grandfather
Grandmother Grandfather Grandmother
81
69 67 HTN DM 78

Aunt Mother Uncle Uncle Uncle Father Uncle Aunt

40 MI 37 31 25 47 DM 45 40 HTN 36

Cousin
Cousin Cousin
78
78 78
Sister The patient Brother
Cousin
78 45 SMKR 78 Cousin Cousin
78
DM HTN
78 78
Brother Sister
Cousin
78 78
78 Cousin

78

Son Daughter Daughter SYMBOLS USED:

78 78 78 Male female

HTN- hypertension SMKR- smoker

DM- diabetes mellitus

MI- myocardial infarction

Deceased
VI. GENERAL ASSESSMENT

Past history:
(-) smoking
(-) alcoholic and beverage drinks
No noted hospitalizations in the past.
Health Care Provider:
DOCTOR
Final Diagnosis:
GOITER
General Appearance:
 conscious
 coherent
Level of sensorium:
 cooperative

EENT:
- Anicteric Sclerae

Breast:
-Non tender

Lungs:
-CBS, equal chest expansion
VII. DEVELOPMENTAL THEORIES AND TASKS

PSYCHSOCIAL DEVELOPMENTAL THEORY: Erik Erickson

Stage: Generativity vs Stagnation: 35-65 years old
This is the longest period of a human's life. It is the stage in which people are usually
working and contributing to society in some way and perhaps raising their children. If a
person does not find proper ways to be productive during this period, they will probably
develop feelings of stagnation.

PSYCHOSEXUAL DEVELOPMENTAL THEORY: Sigmund Freud

Psychosexual Theory:
Genital (12 years of age and older): During this stage, sexual impulses reemerge. If
other stages have been successfully met, adolescents engage in appropriate sexual
behavior, which may lead to marriage and childbirth.

COGNITIVE DEVELOPMENTAL THEORY: John Piaget’s Cognitive theory

Formal operational stage (11 years or older). The use of abstract thinking and deductive
reasoning. General concepts are related to specific situations, and alternatives are
considered. The world is evaluated by testing beliefs in an attempt to establish values
and meaning in life.

MORAL DEVELOPMENTAL THEORY: Carol Gilligan

Moral Development Theory
Level 2- Goodness. Moral judgement is based on shared norms and expectations, and
societal values are adopted. Acceptance by others becomes critical, and the ability to
protect and care for others is seen as the defining characteristics of female goodness.
This characteristic is upheld through beliefs that one is responsible for the actions of
others but that others are responsible for the choices they make. As a woman examines
her self-sacrifice, the second transition occurs, with the woman asking if her own needs
are not also important. A shift of from goodness to truth (as well as a new conception of
goodness) takes place.
VIII. NURSING THEORIES

Hildegard Peplau: Relations Model

Peplau’s theory is the existence of a therapeutic relationship with an individual when a

need is present. The nurse- client relationship evolves in four phases:

 Orientation- client seeks help and the nurse assists the client to understand the
problem and the extent of the need for help.
 Identification- the client assumes a posture of dependence, interdependence, or
independence in relation to the nurse (relatedness). The nurse’s focus is to
assure the person that the nurse understands the interpersonal meaning of the
client’s situation.
 Exploitation- the client derives full value from what the nurse offers through the
relationship. The client uses available services based on self-interest and needs.
Power shifts from the nurse to the client.
 Resolution- in the final phase, old needs and goals are put aside and new ones
adopted. Once older needs are resolved, newer and more mature ones emerge

Jean Watson: Caring Theory

Nursing intervention related to human care originally referred to as curative factors have
now been translated into clinical caritas processes.

 Formation of a humanistic-altruistic system of values becomes “practice of

loving-kindness and equanimity within context of caring consciousness.”
 Installation of faith-hope becomes “being authentically present, and enabling and
sustaining the deep belief system and subjective life world of self and one-being-
cared-for.”
 Assistance with gratification of human needs becomes “assisting with basic
needs, with an intentional caring consciousness, administering “human care
essentials, which potentiate alignment of mind, body, spirit, wholeness, and unity
of being in all aspects of care,” tending to both embodied spirit and evolving
spiritual emergence.
  Systematic use of a creative problem-solving caring process becomes “creative
use of self and all ways of known gas part of the caring process; to engage in
artistry of caring healing practice.

Rosemarie Rizzo Parse: Human Becoming Theory

 Human is becoming is freely choosing personal meaning in situations in the

intersubjective process of relating value priorities.
 Human becoming is co-creating rhythmic patterns or relating in mutual process
with the universe.
 Human becoming is contrascendingmultimensionally.

Sister Callista Roy: Adaptation Model

The goal of Roy’s model is to enhance life processes through adaptation in four
adaptive modes. Individuals respond to needs (stimuli) in one of the four modes.

 The physiological mode involves the body basic physiological needs and ways of
adapting with regard to fluids and electrolytes, activity and rest, circulation and
oxygen, nutrition and elimination, protection, the senses and neurological and
endocrine function.
 The self-concept mode includes two components: physical self, which involves
sensation and body image, and the personal self, which involves self-ideal, self-
consistency, and the moral-ethical self.
 The role function mode is determined by the need for social integrity and refers to
the performance of duties based on given position within society.
 The interdependence mode involves ones relations with significant others and
support systems that provide help, affection and attention.
IX. ANATOMY AND PHYSIOLOGY

The endocrine system is made up of glands that produce and secrete hormones,
chemical substances produced in the body that regulate the activity of cells or organs.
These hormones regulate the body's growth, metabolism (the physical and chemical
processes of the body), and sexual development and function. The hormones are
released into the bloodstream and may affect one or several organs throughout the
body.

Hormones are chemical messengers created by the body. They transfer information
from one set of cells to another to coordinate the functions of different parts of the body.

The major glands of the endocrine system are the hypothalamus, pituitary, thyroid,
parathyroids, adrenals, pineal body, and the reproductive organs (ovaries and testes).
The pancreas is also a part of this system; it has a role in hormone production as well
as in digestion.
The endocrine system is regulated by feedback in much the same way that a thermostat
regulates the temperature in a room. For the hormones that are regulated by the
pituitary gland, a signal is sent from the hypothalamus to the pituitary gland in the form
of a "releasing hormone," which stimulates the pituitary to secrete a "stimulating
hormone" into the circulation. The stimulating hormone then signals the target gland to
secrete its hormone. As the level of this hormone rises in the circulation, the
hypothalamus and the pituitary gland shut down secretion of the releasing hormone and
the stimulating hormone, which in turn slows the secretion by the target gland. This
system results in stable blood concentrations of the hormones that are regulated by the
pituitary gland.

Thyroid Gland - Anatomy & Physiology

The thyroid gland lies in the neck, in front of the upper part of the trachea. Two types of
hormones are produced, which are the iodine containing hormones;
triiodothyronine(T3) and thyroxine (T4). Thyroid hormones regulate the basal
metabolic rate and are important in the regulation of growth of tissues, particularly
nervous tissue. Release stimulated by TSH from the pituitary. The second type of
hormone produced from the thyroid gland is calcitonin, which regulates blood calcium
levels along with parathyroid hormone and acts to reduce blood calcium by inhibiting its
removal from bone.

Thyroid Hormone Actions

T3 and T4 have effects on all body systems and at all stages of life. These include:

Development where thyroid hormones are vital during the fetal period and the first few
months after birth.
Thyroid hormones also promote growth as they enhance amino acid uptake by tissues
and enzymatic systems involved in protein synthesis thus promoting bone growth.
They also help with metabolic actions such as carbohydrate metabolism, as thyroid
hormones stimulate glucose uptake, glycogenolysis, gluconeogenesis.
In fat metabolism they mobilize lipids from adipose stores and accelerate oxidation of
lipids to produce energy (occurs within mitochondria), as well as increasing the size and
number of mitochondria.

Thyroid hormones also increase basal metabolic rate (BMR) in all tissues except brain,
spleen and gonads. The results in increased heat production, increased oxygen
consumption. This increased metabolic rate also results in increased utilization of
energy substrates causing weight loss.

Some of thyroid hormones cardiovascular actions are to increase cardiac output, heart
rate and contractility. They affect the respiratory system indirectly through increased
BMR causing increased demand for oxygen and increased excretion of carbon dioxide.
In the nervous system thyroid hormones are required for myelination of neurons during
the development. They also enhance the sympathetic nervous system (by increasing
epinephrine receptors).

Reproductive system is affected by reduced levels of thyroid hormone causing irregular

cycling and decreased libido. Finally, in the alimentary system, thyroid hormone
increases appetite and feed intake, increases secretion ofpancreatic enzymes and
increases motility.
X. DEFINITION OF TERMS

Hormones: Are chemical messengers that are secreted directly into the blood, which
carries them to organs and tissues of the body to exert their functions.

Tri-iodothyronine(T3): One of the thyroid hormones, an organic iodine-containing

compound liberated from thyroglobulin by hydrolysis. It has several times the biological
activity of thyroxine.

Thyroxine (T4): The main hormone produced by the thyroid gland, acting to increase
metabolic rate and so regulating growth and development.

Glycogenolysis: The breakdown of glycogen to glucose.

Gluconeogenesis: The production of glucose, especially in the liver, from amino acids,
fats, and other substances that are not carbohydrates.
XI. ETIOLOGY

PREDISPOSING FACTORS

If Present Rationale

The body of evidence for genetic vulnerability to

schizophrenia is growing studies show that relatives
Genetics
and  of individuals which schizophrenia have a much
higher probability of developing the disease than
Heredity
does the general population whereas the life time risk
for developing schizophrenia is about 1 percent in
most population studies the siblings have a 5-10
percent risk of developing schizophrenia.

 A tendency to earlier onset in males with the peak

incidence in the early twenties in contrast with the late
age
twenties or early thirties has been consistently
assessed

 Schizophrenia affects males and females equally,

sex
although symptoms often appear earlier in males

The Caucasians and the African Americans are at high

Race
risk for mental disorders

Hormonal pregnancy, puberty and the menopause can affect

changes thyroid function.

PRECIPITATING FACTORS
 Iodine deficiency is the major cause of goiter worldwide,
Iodine
but this is rarely a cause in more economically developed
deficiency
countries that add iodine to salt.

 thiocyanate in tobacco smoke interferes with iodine

Smoking
absorption.

Lithium the psychiatric drug can interfere with thyroid function.

Radiation Radiation therapy particulary to the neck area can cause

therapy abnormal growth in the thyroid causing goiter

 XII. PATHOPHYSIOLOGY

Predisposing Precipitating
Factors: Factors:

-age (males 15-25) -traumatic events in

(females 25-35) childhood
-family history -stress
-structural brain -alcohol
Etiology: unknown
abnormalities -smoking
Combination of biological, -substance abuse
psychological and social factors

Abnormality in the brain’s neurotransmitters (dopamine and serotonin)

Increased level of dopamine

Results in brain overstimulation and excess sensory information

Impaired concentration, thought processes and reality orientation

Positive Negative
symptoms: symptoms:

- Associative - Alogia
looseness - Blunt affect
- Hallucinations - Apathy

If treated: If not treated:

Diagnostic tests: Complications:

- Mental status Severe emotional and
examination Behavioral health problems
- MRI/ CT scan (suicide, violence)
Medical treatment:
- antipsychotics Poor prognosis

Death
Good prognosis
 XIII. SYMPTOMATOLOGY

SIGNS AND SYMPTOMS

If Present Rationale

Difficulty in
 Thyroid growing around the esophagus is making it
Swallowing difficult to swallow

Having a growing thyroid makes it difficult to breath

Difficulty in
because air cannot pass properly due to the blockage of
breathing
airway

 A growing thyroid causes irritation in the throat, which

Coughing
causes coughing.

A tight feeling in
 This is caused by a swollen thyroid gland that compresses
your throat the walls of the throat

 This causes abnormal voice changes due to the

Hoarseness
enlargement of the thyroid gland.
XIV. DIAGNOSTIC TESTS

COMPLETE BLOOD COUNT (CBC) 5/24/2017

Result Range Interpretation

Haemoglobin is a hemoprotein that

functions primarily to carry oxygen and
carbon dioxide throughout the body
Hemoglobin 120 – 160
129 g/L
(hgb) g/L
Normal hemoglobin level indicates that the
The body have adequate haemoglobin to
bind to oxygen molecules.

Hematocrit represents the percentage of

RBCs in the plasma
Hematocrit
0.38 % 0.37 - 0.45
(hct)
Normal hematocrit level indicates a normal
concentration of RBC in the blood

Red blood cells are cells that contain

hemoglobin and its function is to transport
oxygen that is bound to the hemoglobin to
Red blood 4.28 bodily tissues and carry carbon dioxide to
4.0 - 5.0
cells (RBC) 10^2/L the lungs.
Normal RBC count indicates adequate
number of oxygen-transporting cells in the
body
White blood cells are function as the
protective movable army in the body that
defends the body against foreign antigens
White blood 6.6
4.8 - 10.8
cells (WBC) 10^9/L Normal WBC count indicates the body has
a normal immunity and is able to fight
infections, it also indicates that there is no
infection present
Mean Mean corpuscular volume (MCV) is the
corpuscular 89.9 82 - 98 average volume of red cells in a specimen.
volume (MCV) Normal MCV indicates……

Mean The mean corpuscular hemoglobin

corpuscular concentration (MCHC) is a measure of the
hemoglobin 33.6 g/L 33 - 36 concentration of hemoglobin in a given
concentration volume of packed red blood cells.
(MCHC) Normal MCHC indicates…..

Mean
corpuscular Mean corpuscular hemoglobin (MCH) is…..
26-34
hemoglobin Normal MCH indiactes
(MCH)

The blood differential test measures the percentage of each type of

Differential
white blood cell (WBC) in the blood. It also reveals if there are any
count
abnormal or immature cells.

Neutrophils are the ……

Neutrophil 62 % 40 - 70
Normal neutrophil count indicates……
 Lymphocytes are the…….
Lymphocyte 30 % 19 - 48
Normal lymphocyte count indicates……

Monocytes are……..
Monocyte 5% 3-9
Normal monocyte count indicates…….

Eosinophils are…………….
Eosinophil 3% 2-8 Normal eosinophil count indicates………

Basophils are……………
Basophil 0% 0 - 0.5 Normal basophil count indicates………..

264 Platelets are…………

Platelet Count 150 - 400
10^9/L Normal platelet count indicates….

URINALYSIS 2/23/2017

Result Range Interpretation

Chemical Analysis

pH 6.0 5.5 to 7 Urine pH indicates whether the unine is

acidic or alkaline,
 Acidic urine occurs in metabolic acidosis
(diabetic
ketosis), diarrhea, starvation, urinary tract
infections caused by
E. coli, and respiratory acidosis (carbon
dioxide retention).
• Alkaline urine (pH 7.0) occurs in urinary
tract infections caused
by urea-splitting bacteria, renal tubular
acidosis, chronic renal
failure, and respiratory alkalosis (due to
hyperventilation)

Urinary specific gravity (SG) is a measure

of the concentration of solutes in the urine

Low specific gravity may occur in patients

Specific with diabetes insipidus (decreased or
1.015 1.005-1.030 absent ADH), glomerulonephritis
Gravity
with pyelonephritis, severe renal damage.
• High specific gravity can occur in diabetes
mellitus, increased secretion of ADH,
nephrosis, congestive heart failure

The glucose urine test measures the

amount of sugar (glucose) in a urine
sample. The presence of glucose in the
urine is called glycosuria or glucosuria.

Glucose Negative Glycosuria occurs in patients with elevated

serum glucose levels (e.g. diabetes mellitus
see chapter on hyperglycaemia) or in the
presence of a reduced renal threshold and
reduced glucose reabsorption in renal
tubular disease and pregnancy

Proteinuria meansdo Increased renal

tubular secretion,increased glomerular
Protein Negative filtration (glomerular disease), nephrotic
syndrome, pyelonephritis,
glomerulonephritis, malignant hypertension

Urine Flowcytometry
 When the WBC count in urine is high, it
means that there is inflammation in the
urinary tract or kidneys. The most common
WBC 1 /uL 0 – 17 /uL
cause for WBCs in urine (leukocyturia) is a
bacterial urinary tract infection (UTI), such
as a bladder or kidney infection.

This test is used to detect hemoglobin in

the urine (hemoglobinuria). Hemoglobin is
an oxygen-transporting protein found inside
red blood cells (RBCs). Its presence in the
urine indicates blood in the urine (known as
RBC 4 /uL 0 – 11 /uL
hematuria). The small number of RBCs
normally present in urine usually result in a
"negative" test. However, when the number
of RBCs increases, they are detected as a
"positive" test result.

Epithelial cells in urine may be a cause for

concern if the numbers are higher than
normal. The sloughing of epithelia is quite a
Epithelial normal process of the body sheddingdead
4 /uL 0 – 17/uL
Cells cells and creating new ones. If epithelial
cells are high in your urine it could signal a
problem with your kidneys or an infection in
your urinary system.

Urinary casts are formed only in the distal

convoluted tubule (DCT) or the collecting
duct (distal nephron). The proximal
convoluted tubule (PCT) and loop of Henle
Cast 0 /uL 0 -1
are not locations for cast formation. Hyaline
casts are composed primarily of a
mucoprotein (Tamm-Horsfall protein)
secreted by tubule cells.

Bacteria 43 /uL 0 - 278 Urine is normally sterile, which means that

it contains no bacteria. A small number of
bacteria may be found in the urine of many
healthy people. This is usually considered
to be harmless. However, a certain level of
 bacteria can mean that the bladder,
urethra, or kidneys are infected.

THYROID FUNCTION TEST 2/242017

Result Range Interpretation

Thyroid Stimulating Hormone measures a

pituitary hormone that is a messenger to
the thyroid gland.
Thyroid 1.39
stimulating 0.34- 5.60 In general, high TSH is associated with
uIU/mL
hormone LOW thyroid/underactive/hypothyroidism,
(TSH) and low TSH is associated with HIGH
thyroid/overactive/hyperthyroidism.

Free thyroxine (free T4) tests are used to

help evaluate thyroid function and diagnose
thyroid diseases, including hyperthyroidism
and hypothyroidism, usually after
discovering that the thyroid stimulating
Free thyroxine 11.91 hormone (TSH) level is abnormal.
7.5-21.1
(FT4) pmol/L
In general, high free T4 results may
indicate an overactive thyroid gland
(hyperthyroidism), and low free T4 results
may indicate an underactive thyroid gland
(hypothyroidism).
XV. MEDICAL AND SURGICAL MANAGEMENT

PHARMACOLOGICAL MANAGEMENT:

Generic Name: Ferrous Sulfate

Brand Name: Fer-Iron, Apo-Ferrous Sulfate

Pharmacotherapeutic: Enzymatic mineral.

Clinical: Iron preparation

Action: essential component in formation of Hgb, myoglobin, enymes. Promotes

effective erythropoiesis and transport, utilization of oxygen.

Pharmacokinetics: absorbed in duodenum and upper jejunum. Ten percent absorbed

in patients with normal iron stores; increased to 20%-30% in those with inadequate iron
stores. Primarily bound to serum transferrin.

Uses: Prevention, treatment of iron deficiency anaemia due to inadequate diet,

malabsorption, pregnancy, blood loss.

Contraindications: Hemochromatosis, hemosiderosis, haemolytic anemias, peptic

ulcer disease, regional enteritis, ulcerative colitis.

Interactions: Drug: Antacids, calcium supplements, pancreatin, pancrelipase may

decrease absorption of ferrous compounds. May decrease absorption of etidronate,
quinolones, tetracycline. Food: Eggs, milk inhibit ferrous fumarate absorption. Lab
values: May increase serum bilirubin, iron. May decrease serum calcium. May obscure
occult blood in stools.

Indications/Routes/Dosage: Iron deficiency anaemia. PO: Adults, Elderly: 325 mg 2-4

times a day. Prevention of iron deficiency. PO: Adults, Elderly: 325 mg/day.
Side Effects: Occasional: Mild, transient nausea. Rare: Heartburn, anorexia,
constipation, diarrhea.

Adverse Effects: Large doses may aggravate existing GI tract disease (peptic ulcer,
regional enteritis, ulcerative colitis). Severe iron poisoning occurs most often in children,
manifested as vomiting, severe abdominal pain, diarrhea, dehydration, followed by
hyperventilation, pallor, cyanosis, cardiovascular collapse.

Nursing Considerations:

 Monitor daily pattern of bowel activity and stool consistency.

 Monitor serum iron, total iron-binding capacity, reticulocyte count, Hgb, ferritin.

 Assess for clinical improvement, record relief of iron deficiency symptoms

(fatigue, irritability, pallor, paresthesia of extremities, headache).

 If GI discomfort occurs, take after meals or with food.

 Do not take within 2 hours of antacids.

SURGICAL MANAGEMENT:

Thyroidectomy:
 XVI. NURSING CARE PLAN

NURSING CARE PLAN- 1

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Acute Pain r/t At the end 1. Established rapport. Goal met
injuring of 8 hour Rationale: To get patient’s cooperation. as
“Dili kayo agents shift, evidenced
kokasturya (Surgical patient 2. Monitored VS. by
kay sakit pa” incision) will: Rationale: To have baseline data. decreased
as verbalized secondary to pain scale
by the thyroidectom - report 3. Noted location of surgical procedures. from 6/10
patient y decreased Rationale: As this can influence the to 1/10
pain scale amount of postoperative pain
Objective: from 5/10 experienced.
Rationale: to 2/10
- (+) Facial Acute pain is 4.Assessed for referred pain, as
grimace. generally - (-) facial appropriate
accepted as grimace Rationale: To help determine possibility
- Pain scale being of of underlying condition or organ
of 5/10 recent onset dysfunction requiring treatment.
and limited
VS taken as short 5. Accepted client’s description of pain.
follows. duration. It Rationale: Pain is a subjective
T: 36.7 usually has a experience and cannot be felt by others.
PR: 87 temporal
RR: 20 (follows 6. Observed non-verbal cues and pain
BP: 120/80 immediately behaviors and other objective defining, as
after noted.
surgery/traum Rationale: Observations may not be
a) and causal congruent with verbal reports or may be
(has a known only indicator present when client is
cause) unable to verbalize.
relationship
to injury or 7.Provided comfort measures
disease. Rationale: To promote non
pharmacological pain management.
(medical
surgical 8. Instructed in and encourage case of
nursing book, relaxation techniques.
 brunner and Rationale: To distract attention and
suddarth 13th reduce tension.
edition).
9. Administered pain reliever as
necessary.
Rationale: To maintain “acceptable” level
of pain.

10. Evaluated and document client’s

response to analgesia.
Rationale: Increase or decrease dosage
helps in self-management of pain.

11. Encouraged adequate rest period.

Rationale: To prevent fatigue that can
impair ability to manage pain.

NURSING CARE PLAN- 2

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Disturbed After 8 1. Established rapport. Goal met as

body image hours of Rationale: To get patient’s cooperation. evidenced by
Patient r/t enlarged nursing patient’s
verbalized thyroid intervention 2. Monitored VS. Verbalization
“maconcious , the patient Rationale: To have baseline data. about
kopag tan- will acceptance
awonkosamg Rationale: verbalize 3. Assessed mental/physical influence of self and
atao” Nonverbal understandi of illness/condition on the client’s the patient
response to -ng of body emotional state (e.g., diseases of the looks at the
actual or changes endocrine system, use of steroid incision site
Objective: perceived related to therapy, and so on). without
change in disease Rationale: Those factors influence the feelings of
VS taken as structure process client’s view of self. sadness and
follows. and or remorse
T: 36.7 function, 4. Evaluated level of client’s knowledge
PR: 87 verbalizatio of and anxiety related to situation.
RR: 20 n of feelings Rationale: To observe emotional
BP: 120/80 that reflect changes.
an altered
view of 5. Have client describe self, noting what
one's body is positive and what is negative.
in Rationale: To be aware of how client
appearance believes others see self.
, structure,
or function. 6. Determine ethnic background and
cultural/religious perceptions and
considerations.
(medical Rationale: Different cultures have
surgical different perceptions of certain
nursing conditions.
book,
brunner 7. Assessed client’s current level of
and adaptation and progress.
suddarth Rationale: To determine need for
13th further interventions.
edition).
8. Listened to client’s comments and
responses to the situation.
Rationale: Different situations are
upsetting to different people, depending
on individual coping skills and past
experiences.

9. Identified previously used coping

strategies and effectiveness.
Rationale: To determine the clients
coping strategies.

NURSING CARE PLAN- 3

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Nausea r/t At the end 1. Established rapport. Goal met

pharmaceutic of 8 hour Rationale: To get patient’s cooperation. as
Patient al agent shift, evidenced
verbalized” (anesthesia) patient 2. Monitored VS. by normal
murag ko secondary to will: Rationale: To have baseline data. vital signs
kasukaon na total and patient
dili” thyroidectom Be free of 3. Asked the client about situations that showed no
y signs and are perceived as distasteful, anxiety- signs and
(+) Gagging symptoms inducing or threatening symptoms
sensation of nausea Rationale: help in identifying those of nausea,
Rationale: and situations and limiting the client’s (-) gagging
vomitting exposure to them sensation
Objective: Postoperative
nausea and 4. Determined if nausea is potentially
VS taken as vomiting is self-limiting and/or mild or if severe
follows. one of the and prolonged.
T: 36.7 most Rationale: Suggests severity of effect on
PR: 87 common fluid and electrolyte balance and
RR: 20 causes of nutritional status
BP: 120/80 patient
dissatisfactio 5. Administered and monitor response to
n after medications used to treat underlying
anaesthesia, cause.
with reported Rationale: To determine effectiveness of
incidences of treatment.
30% in all
post-surgical 6. Provided clean peaceful environment.
patients and Rationale: Offending odors may
up to 80% in stimulate or worsen nausea.
high-risk
patients 7. Encouraged deep slow breathing.
Rationale: To promote relaxation and
refocus attention away from nausea.
(Medical
surgical 8. Avoided sudden change of position.
nursing book, Rationale: This may help prevent nausea
brunner and associated with motion sickness.
suddarth 13th
 edition). Dependent:
9. Administer antiemetic as ordered.
Rationale: To control or prevent nausea.

NURSING CARE PLAN- 4

Assessment Diagnosis Planning Intervention Evaluation

Objective: Risk for At the end of 1. Established rapport. Goal met

infection r/t 8 hour shift, Rationale: To get patient’s as
With post op traumatized patient will: cooperation. evidenced
dressing, dry tissue by normal
and intact secondary to - Identify and 2. Monitored VS. vital signs
thyroidectom demonstrate Rationale: To have baseline data. and patient
VS taken as y interventions showed no
follows. to prevent 3. Observed and reported signs of signs and
T: 36.7 infection infection such as redness, warmth, symptoms
PR: 87 Rationale: discharge, and increased body of infection,
RR: 20 Skin is a - Patient will temperature. (-) foul
BP: 120/80 natural show no Rationale: With the onset of infection smelling
barrier signs and the immune system is activated and odor at
against symptoms of signs of infection appear. incision site
infection. infection
Even with such as 4.Noted and reported laboratory values
many fever and (e.g., white blood cell count)
precautions foul smell at Rationale: Laboratory values provide
and protocols incision site a
to prevent global view of the client's immune
infection in function.
place, any
surgery that 5. Used proper hand washing
causes a techniques before and after giving care
break in the to client.
skin can lead Rationale: Hand washing significantly
to an decreases the number of
infection. microorganisms.
Doctors call
these 6. Provided wound healing such as
infections cleaning of wound.
surgical site Rationale: To reduce risk for infection.
infections
(SSIs) 7. Kept area around wound dry and
because they intact.
occur on the Rationale: Wet area can be lodge
part of the area
body where of bacteria.
the surgery
took place. 8. Reviewed environmental factors.
Rationale: To assess if there is need
(medical of avoidance or modification of
surgical environment to reduce risk of infection.
nursing book,
brunner and Dependent
suddarth 13th
edition). 9. Administered antibiotics as ordered.
Rationale: To aid in the prevention of
infection.

10. Assisted in changing dressing as

needed.
Rationale: To promote healing to the
incision.
 NURSING CARE PLAN- 5
Assessment Diagnosis Planning Intervention Evaluation

Subjective: Risk for At the end 1. Established rapport. Goal met

“Dili kayo bleeding r/t of 8 hour Rationale: To get patient’s cooperation. as
kokasturya surgery shift, patient evidenced
kay sakit pa” secondary to will: 2. Monitored VS. by normal
as verbalized total Rationale: To have baseline data. vital signs
by the thyroidectom - show no and patient
patient y signs and 3. Noted client report of pain in specific showed no
symptoms areas. signs and
Objective: of bleeding, Rationale: Can help identify bleeding symptoms
- (+) Facial Rationale: (-) into tissues, organs or body cavities. of bleeding,
grimace. Surgical hoarseness (-)
problems can and 4. Assessed skin color and moisture, hoarseness
- Pain scale cause frequent urinary output and level of and
of 5/10 postoperative swallowing consciousness. frequent
bleeding. For Rationale: Changes in these signs may swallowing
VS taken as example, be indicative of blood loss affecting
follows. blood vessels systemic circulation or local organ
T: 36.7 may need to function.
PR: 87 be secured,
RR: 20 or stitches 5. Reviewed laboratory data.
BP: 120/80 may have Rationale: To evaluate bleeding risk.
come apart. An abrupt drop in Hb of 2g/dl can
Injury to other indicate active bleeding.
organs may
also have 6. Instructed client to avoid forceful
occurred blowing, coughing, sneezing, and
during straining.
surgery. Rationale: These activities can
damage mucous membrane increase
(medical risk for bleeding.
surgical
nursing book, 7. Monitored the incision site for any
brunner and signs of bleeding.
suddarth 13th Rationale: To observe incision site as
edition). having bleeding tendency.
Dependent:
9. Gave medications as ordered.
Rationale: To prevent bleeding.
XVII. DISCHARGE PLANNING

1. The treatment regimen was instructed to the patient to comply at

home every day

R: To prevent occurrence and re-occurrence of signs and symptoms

of the disorder
2. Discussed to the family member the side effects of the drug.

R: For the family to know and expect the effect of the drug to the
client
3. Emphasized the importance of taking medications in accordance to
the prescribed schedule and dosage to the client.

Medication R: To Ensure the effectiveness of the drug to the patient

4. Encourage the family members to always seek medical advice and
prescription in having drugs rather than those of that are brought
over the counter.

R: This will help the health status of the client as well as his family
and to provide effective outcome.
5. Instructed patient not to discontinue the medication

R: Direct abruption drug can cause rebound effect that can worsen
the client’s condition

Exercise 1. Encouraged client to have daily exercise

R: To promote wellness and to maintain body fitness to the client

2. Advice the client to have adequate rest.

R: To prevent exhaustion to the client

3. Instructed the client to avoid engaging in physical activities when
taking the medication

R: Based on the side effects, patients can be dizzy which can cause
potential injuries.
 4. Get regular sleep
R: Tell the patient to try to sleep 6 to 8 hours of sleep each night.

1. Maintenance of medication should be regularly taken

R: To prevent any occurrences of signs and symptoms of the

disorder
2. Instructed the client to comply with the treatment regimen

R: Lack of compliance of the medication is usually the cause why

Treatment
there is a relapse on the manifestation of the disorder
3. Inform client the importance of continuing medication therapy

R: The therapy does not give full assurance in curing the disorder,
somehow, this may be helpful and beneficial to the client

1. Instructed the client to take a bath and wear clean clothing everyday

R: To maintain a good hygiene and be well groomed

2. Encouraged client to wash hands before and after meals

R: To prevent acquiring disease and maintain proper hygiene

3. Advise to trim finger and toe nails
Hygiene
R: To maintain cleanliness and accumulation of microorganisms
4. Encouraged to maintain good oral hygiene by frequently brushing
and flossing teeth.

R: To prevent bad breath and tooth decay

 1. Emphasized the importance of follow-up check up with the physician

R: Physician knows best in managing patient’s condition

2. Encouraged to have adequate rest and sleep
Out- patient
order R: Since client may experience in difficulty falling asleep at night.
Morning or afternoon maybe the best time for him to have adequate
rest and sleep.

1. Encouraged client to eat three times day

R: To promote a healthy body and to promote optimum nutritional

status
2. Instruct the client to drink 6-8 glasses of water per day

R: Increase intake would facilitate body waste removal and to

prevent dehydration
3. Encourage to eat vegetables and fruits if not contraindicated

R: To promote well balanced diet and it is highly nutritional

Diet 4. Avoid eating or drinking foods containing caffeine such as coffee
and beer

R: It is prohibited when taking psychotic medications because it can

alter the effect of the drugs.
5. Instructed client to have other nutritional supplements such as milk
and juice

R: To complement and enhance body’s mechanism against possible

disease.
XVIII. PROGNOSIS

General prognosis

The general prognosis is good, this means that patient pie condition can be alleviated,

with the cooperation and strict compliance of the therapeutic orders made by the doctor,

with the support groups of the family, the patient can adapt to the changes in her body

image after her surgery and look at the surgical site without feelings of remorse or

sadness.

Goiter in general can range from mild to moderate in severity, A simple goiter may

disappear on its own, or may become larger. Over time, the thyroid gland may stop

making enough thyroid hormone. This condition is called hypothyroidism.

In some cases, a goiter becomes toxic and produces thyroid hormone on its own. This

can cause high levels of thyroid hormone, a condition called hyperthyroidism.

After the surgery, patient pie’s condition seemed to have improved greatly and the

patient is complying with the prescribed medical treatment

Results:
Bad: 0
Fair: 2
Good: 4
 Criteria Bad Fair Good Justification

Having diagnosed with goiter at an

early stage is a needed justification
1. Onset of illness √ because this is a serious disease,
we rated the onset of disease as
good

Willingness to seek for medical

assistance or treatment simplifies
2. Duration of illness √ that the patient wanted to be cured
as soon as possible

The patient and the family complies

3.Willingness to take the the medication treatment regimen
medicines/compliance to √ for the disease, the patient was able
treatment regimen to verbalize the need for the
treatment regimen

4. Precipitating factors
(eg. Environment, family, The patient has been subjected to
lifestyle, health and √ precipitating factors
sanitary practices)

The patient has been subjected to

5. Predisposing factor √ predisposing factors

The family was much supportive

6. Family support √ and never left the patient alone, the
family
XIX. RECOMMENDATIONS

As nurses, our vital role is to provide health care and deliver services in the
hospital to improve the health status of each individual. This nursing care study is
important for us because it in enables to give the proper health teaching to our chosen
client.
We recommended this case to the following persons and institution for the further
improvement of the study.

TO THE FAMILY:
This study for the family of our patient to follow the treatment prescribed such as
to take the medications as on time and right dosage and other recommended measures
by the physicians, encourage having adequate rest to hasten the recovery of the
patient. Through the adherence of fulfillment of the suitable medical management, for
the fast recovery of the patient.

TO THE STUDENT:
We recommended this study for the students as a reference for the future cases,
in order to have some based line data to refer.

TO THE COLLEGE OF NURSING

We recommended this study to our department for giving us a precise details and
an access of further study of this case. We advocate also for giving us an abundance
time to research in order to prevent typographical and grammatical errors.

TO THE DAVAO MEDICAL SCHOOL FOUNDATION HOSPITAL

We recommended this study to Davao medical school foundation for them to
able to evaluate and appreciate the said case and share this as a reference and
information having those patients who has certain condition.
XX. BIBLIOGRAPHY/ REFERENCES

Blackwell’s Nursing Dictionary Second Edition (2011), Blackwell’s Publishing Ltd.

Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. G. (2016). Brunner
&Suddarth’s Canadian textbook of medical-surgical nursing (3rd Canadian ed.).
Philadelphia: Lippincott Williams & Wilkins
Fundamentals of Nursing Eight Edition, Kozier&Erb’s, Pearson, Prentice Hall
gnatavicius, D. D., Workman, M. L., & Henderson, L. (2015). Medical-surgical nursing:
Critical thinking for collaborative care (7th ed.). Toronto: Elsevier Saunders. (ISBN
978-1-4377-2801-9)
Jarvis, C. (2014). Physical examination & health assessment (2nd Canadian ed.). St.
Louis, MO: Saunders. (ISBN 978-1-9266-4872-9)
Lippincott’s Nursing Drug Handbook, Lippincott, 2014
Nurses Pocket Guide, Diagnoses Prioritized Interventions, and
rationales,MarilynnE.Doenges,Mary Frances Moorhoouse,Alice C. Murr, 13 th
edition.